title: Promoting universal financial protection: a policy analysis of universal health coverage in Costa Rica (1940-2000).
abstract: BACKGROUND
  This paper explores the implementation and sustenance of universal health coverage (UHC) in Costa Rica, discussing the development of a social security scheme that covered 5% of the population in 1940, to one that finances and provides comprehensive healthcare to the whole population today. The scheme is financed by mandatory, tri-partite social insurance contributions complemented by tax funding to cover the poor.
  
  
  METHODS
  The analysis takes a historical perspective and explores the policy process including the key actors and their relative influence in decision-making. Data were collected using qualitative research instruments, including a review of literature, institutional and other documents, and in-depth interviews with key informants.
  
  
  RESULTS
  Key lessons to be learned are: i) population health was high on the political agenda in Costa Rica, in particular before the 1980s when UHC was enacted and the transfer of hospitals to the social security institution took place. Opposition to UHC could therefore be contained through negotiation and implemented incrementally despite the absence of real consensus among the policy elite; ii) since the 1960s, the social security institution has been responsible for UHC in Costa Rica. This institution enjoys financial and managerial autonomy relative to the general government, which has also facilitated the UHC policy implementation process; iii) UHC was simultaneously constructed on three pillars that reciprocally strengthened each other: increasing population coverage, increasing availability of financial resources based on solidarity financing mechanisms, and increasing service coverage, ultimately offering comprehensive health services and the same benefits to every resident in the country; iv) particularly before the 1980s, the fruits of economic growth were structurally invested in health and other universal social policies, in particular education and sanitation. The social security institution became a flagship of Costa Rica's national development strategy which reinforced its political importance and contributed to its longer-term sustainability and that of UHC.
  
  
  CONCLUSIONS
  UHC has been achieved in Costa Rica because it was supported at the highest political level within a favourable socio-economic and political context. Once achieved, UHC became an entitlement for the population and now enjoys broad public support.
authors.forename: Juan Rafael
authors.initials: JR
authors.lastname: Vargas
authors.forename: Jorine
authors.initials: J
authors.lastname: Muiser
mesh_terms: D003364:Costa Rica / Q000453:epidemiology; D005069:Evaluation Studies as Topic; D018166:Health Care Reform / Q000379:methods*; D006296:Health Services / Q000191:economics*; D006801:Humans; D007354:Insurance, Major Medical / Q000191:economics; D004364:Pharmaceutical Preparations / Q000191:economics; D011050:Policy Making; D019472:Universal Health Insurance; D035862:Vulnerable Populations / Q000331:legislation & jurisprudence*
chemical_list: D004364:Pharmaceutical Preparations